Application of EMDR Therapy for Borderline Personality Disorder

Pacing History Taking to Limited Affect Tolerance Capacities.

Issues of pacing and affect tolerance must be kept in mind when exploring the client’s history and current difficulties. Clients with BPD vary in their capacities to manage the feelings and the memories that are invariably triggered in examining their current maladaptive coping strategies and their generally complex early and adult histories. For example, although some clients may be capable of completing a self-report instrument like the FECS on their own, many find this solitary task overwhelming and destabilizing. These clients need to complete the FECS as a collaborative interview over several sessions with the support and guidance of the clinician. Clinicians need to actively monitor the degree to which clients with BPD feel activated by the history-taking process and to be ready to slow down and shift the focus to developing containment, presentification, and affect regulation skills. A standardized approach to history taking is not adequate for those with complex histories of neglect and trauma. What can be a useful style for one client may be completely inadequate for another. Following guidelines and standards should not make us forget each patient’s specific situation and characteristics. Decision making in cases with BPD is more accurate when it is based on a well-bounded therapeutic relationship and a good knowledge in the clinician about the disorder and the AIP model. As Shapiro (2001) states, “It is better to provide practitioners with a conceptual framework or model to serve as a guide to their clinical practice than merely to give them an inflexible step-by step [sic] procedure for implementing EMDR” (p. xiii). In working with patients with BPD, these words become especially relevant.

Therapeutic Relationship.

The most challenging aspect of the treatment of the client with BPD is to establish a therapeutic relationship that is both supportive and well bounded with clients who present pronounced difficulties in adult attachment and interpersonal connection. One of the most challenging aspects of treating those with BPD is the management of the strong emotional reactions that arise in the therapist during EMDR sessions (Leeds & Mosquera, 2012; D. Mosquera, 2012b; D. Mosquera & Gonzalez, 2011a, 2011b). Clinicians need to have the affect tolerance to remain reflective about the significance of the strong emotions that can be evoked in them when clients with BPD express vehement emotions (Dworkin, 2005). These countertransference responses can be the doorways to recognizing essential issues to be addressed skillfully or to involuntary reenactments of the client’s or clinician’s or both prior adverse experiences (Dalenberg, 2000). Appropriate specialty education, training, and consultation are indicated when developing these therapeutic skills. In some cases, clinicians need to address the foundations of their own affect tolerance issues in personal EMDR therapy. As part of developing the therapeutic alliance with clients with BPD, clinicians should actively inquire about clients’ problems from previous psychotherapies to prevent or minimize recurrences of these past relational difficulties in the present therapeutic relationship.

Psychoeducational Interventions.

Psychoeducation should be provided to the client from the initial stage of the therapy (about defenses, problem solving, emotions, needs and especially self-care), helping the client to understand his or her problems, to acquire perspective, and to develop resources that he or she will need before trauma reprocessing. This process need not be extensive in all cases. Indeed, in some cases, resolving relevant traumatic memories as soon as possible can be the best stabilization intervention. Psychoeducation should not be considered as a time-limited intervention with patients with BPD but a longitudinal one. It is often necessary to introduce adaptive information all along the therapeutic process. For example, information about healthy attachment should be introduced in Phase 1 during history taking, addressed more specifically with self-care work, and reintroduced as interweaves during Phases 4–7.

Working on Self-Care Patterns.

Self-care patterns are usually problematic in clients with BPD. They tend to lack adequate self-care habits and to focus on external recognition or immediate satisfaction. They have difficulties protecting themselves and establishing healthy boundaries. They lack a healthy balance between caring for themselves and caring for others. They often cannot tolerate positive affect. They have problems asking for help—sometimes being extremely dependent, other times not allowing others to help them. Many individuals with BPD mistreat themselves internally through negative self-dialogue or resort to overtly self-harming behaviors. Specific procedures for improving healthy self-care patterns often need to be applied in this clinical group (Gonzalez & Mosquera, 2012; D. Mosquera, 2012a) in the preparation phase. In complex trauma cases, RDI (Korn & Leeds, 2002; Leeds, 2009) should be extended to include self-care procedures and specific coping skills development (Gonzalez & Mosquera, 2012; D. Mosquera, 2004), giving priority to targets that support healthy functioning in normal activities of day-to-day functioning: regular sleep, regular exercise, ordered eating, freedom from substance abuse, social support, and economic stability. A “test” can be done to see how clients respond to the positive affect in RDI because in rare cases paradoxical (adverse) responses have been reported to RDI procedures in clients with impaired positive affect tolerance (Leeds, 2009, p. 120).

Coping With Urges for Deliberate Self-Harm and Suicidal Threats.

Of all the issues that may be encountered in the treatment of those with BPD, deliberate self-harm and threats of suicide are the two aspects that often present the greatest relational challenge for the therapist. The patient who self-injures or thinks about killing himself or herself poses a complex situation at the relational level, and being aware of our emotional responses as clinicians is a central aspect of the therapeutic response. The hopelessness and despair of patients who sees no meaning in life can lead clinicians to see them as lost cases. On the other hand, some therapists can become overly involved in taking responsibility for the patient’s life, which invariably leads to a dead end in the therapeutic process. Deliberate self-harm and suicidal threats are multifaceted problems that may be related to a lack of emotional regulation, to negative patterns of self-care, to unprocessed guilt, and to relational issues.

The management of these issues needs to be developed as part of a comprehensive case conceptualization because with different clients, similar behaviors will not respond successfully to the same interventions. A client who threatens or attempts suicide because he or she feels incapable of managing ongoing problems may respond best to a family intervention to mobilize more support. In other cases with suicidal threats, the correct intervention would be to develop better self-care procedures and stronger boundaries to decrease his or her dependency on others and to help focus on his or her own resources. A client who tends to cut himself or herself because he or she lacks adequate regulatory capacities may benefit from a psychoeducational approach as described in the next section on emotional regulation. In other cases where self-harming behavior is strongly related to irrational thoughts of guilt (e.g., “It’s my fault”), the most powerful stabilization intervention may be to reprocess a core memory linked with this negative cognition. The targets for reprocessing in these cases are not the self-harming behaviors themselves, but rather the circumstances surrounding the first time in which self-harm occurred, the origin of the negative beliefs associated with the problem, and memories that can be identified through an affect, cognitive or action urge bridge (Leeds, 2009; Watkins, 1971, 1990).

As in every EMDR procedure performed with clients with BPD, a firm, supportive, and well-bounded relationship is crucial to managing these challenging situations. The client must be held as responsible over his or her choices and behaviors, although still feeling that he or she is being supported by the clinician. A plan for dealing with self-harming and suicidal threats should be developed for each specific case with the client and any family members who are involved.

Developing Capacities for Emotional Regulation.

Clients with BPD are prone to intense emotional states that they feel unable to manage, or which they amplify through secondary emotional reactions (e.g., becoming angry because they feel sadness). From one perspective, they seem to tolerate a broad range of emotional reactivity and yet at the same time they often demonstrate an extremely limited tolerance for some specific emotions. Clients with BPD need to learn to accept all their emotional reactions and to place them in situational contexts so that they can understand what triggers them (including past and present events). Psychoeducation about emotions and their functions is crucial for them to realize that feeling hurt and angry does not mean that they are “disgusting,” “defective,” or “in the wrong.”

In the early stages of therapy, it is essential to encourage self-observation because clients with BPD tend to become overwhelmed by their emotions without reflecting on their significance. Developing a meta-cognitive perspective (Fonagy, Gergely, Jurist, & Target, 2002) is a basic regulatory achievement in clients with BPD, who in that way may become aware of their reactions. This “meta” perspective is also essential to facilitate the capacity for dual attention (to past and to present) necessary for effective EMDR memory reprocessing in Phases 4–7. For example, a client with BPD became angry at herself after she opened up to someone who subsequently betrayed her. She reported that her initial emotion was sadness, but that she immediately began insulting herself for being weak and emotional. She was asked to notice what, if anything, changed if she looked at her sadness without judgment and with total acceptance and then did a set of BLS. She then reported she was able to feel compassion for herself. With another set of BLS, her self-compassion increased and she began to think about warning signs of untrustworthiness in that relationship. Then she added that she could learn from this experience.

When clients report excessive fears of others’ adverse reactions to their appropriate limit setting or self-directed actions, the origins of these fears can be identified through history taking or the use of an affect bridge and then reprocessed. Self-distracting activities may be more helpful than containment work because these clients habitually tend to contain too much until they explode. Externally driven regulatory strategies (desperately calling friends or relatives, searching for “real” romantic love, etc.) should gradually change to learning to self-regulate (through supportive internal dialogue, changing attentional focus, etc.). Magical solutions should be turned toward realistic strategies. Self-care procedures can help these clients understand their emotional states, to accept them and look at themselves compassionately without judgment, and to set boundaries in relationships. Emotion regulation interventions should not be understood merely as a preparation phase of the treatment previous to starting reprocessing. Both interventions can be combined dynamically depending on each patient-specific characteristics. In some cases, the best self-regulation intervention is to reprocess unresolved core traumatic experiences of being invisible, not being cared for or having no one to turn to for support and protection.

Focused Work on Substance Abuse.

Alcohol and drug abuse are frequently co-occurring disorders in BPD (Paris & Zweig-Frank, 2001; Trull, Sher, Minks-Brown, Durbin, & Burr, 2000; Zanarini, Frankenburg, Hennen, Reich, & Silk, 2004; Zimmerman & Mattia, 1999) that should be specifically explored. Substance abuse is often related to the limited capacities for emotional self-regulation observed in individuals with BPD and is a frequent ingredient in the myriad of complex interactions that confounds the treatment of borderline pathology and requires specific approaches. Referral to an evidence-based group treatment for substance abuse such as seeking safety (Najavits, 2002; Najavits, Weiss, Shaw, & Muenz, 1998) may be indicated in the early phases of treatment in parallel with the development of the therapeutic relationship and treatment plan to support development of abstinence. Individual EMDR treatment focused on the development of coping skills (Korn & Leeds, 2002) and on treatment of current relapse triggers (Hase, 2010; Hase, Schallmayer, & Sack, 2008; Hofmann, 2004, 2010; Popky, 2005) may also need to be integrated into the treatment plan.

Some clients may need to be referred to residential or outpatient treatment programs early in their individual treatment to support their achieving abstinence or in overcoming the risk of dangerous substance abuse related behaviors (e.g., alcoholic blackout or drug overdose). In other cases, they may have repeatedly failed to benefit from such treatment programs and may need focused EMDR treatment on current relapse triggers (Hase, 2010; Hase et al., 2008; Hofmann, 2004, 2010; Popky, 2005) or even on relevant early traumatic memories. For example, a 43-year-old male client presented compulsive drinking and severe aggressive behaviors when under the effects of alcohol. The risk of him hurting someone was high, so his therapist referred him to a residential alcohol treatment program. After 1 month at the hospital, he was thrown out because of frequent interpersonal problems with other patients. His therapist then decided to attempt EMDR reprocessing on an early memory connected with a feeling of powerlessness and guilt that preceded his worst episodes of drinking. Successful reprocessing of that memory ended the problematic behaviors and made it possible for his outpatient therapy to continue. In cases such as this example, conservative work on preparation phase tasks for skills building and self-regulation may be inadequate to meet a client’s need to address one or more early memories that underlie reactive behaviors or recurring relapses.

Working on Defenses.

In the most general sense, psychological defenses involve a range of internal and external coping behaviors that serve to avoid conflicted feelings and impulses (McCullough, 2003). Defenses can be understood as protections, as affect phobias (McCullough, 2012) or interoceptive phobias of trauma-derived mental actions (van der Hart et al., 2006). They should not be confronted or bypassed in a forced way. Rather they should be approached progressively at a pace the client can tolerate (Gonzalez & Mosquera, 2012; McCullough, 1997). Psychoeducation is a basic intervention in this regard. McCullough (2012) describes this step as defense recognition.

Defenses can often be turned into therapy allies when client and therapist understand their underlying function. When the client is able to identify a defense that the therapist believes is blocking the therapeutic process, it is sometimes possible to reprocess the defense with specific EMDR interventions (Gonzalez & Mosquera, 2012; Knipe, 1999, 2003, 2005, 2009, 2010a, 2010, 2010c; Leeds, 2009, p. 164; Leeds, 2012; Shapiro, 2001, pp. 192–197). For example, a patient presented frequent defensive attitudes in therapy such as minimization, tending to engage in a superficial conversation and avoidance, and cancelling or arriving late to his appointments. The therapist identified his avoidance tendencies as a central issue and selected them as current triggers so they could be reprocessed. Following this therapeutic compliance and engagement improved.

Specific Procedures for Self-Differentiation.

A relevant point that should be addressed is self-differentiation. Harter (1999) reviews different perspectives about the construction of the self-concept and proposes a developmental perspective that explains how early interaction with caregivers (frequently disturbed in patients with BPD) shapes the adult representations of the self. Many individuals with BPD present a lack of differentiation of the self in which the perception of the self contains a mixture of emotions from the self and other people. That is, in the undifferentiated self of clients with BPD, there is a commonality between internal and external perceptions of emotions. Kernberg (1993) describes interventions to address this issue as the first step for treating borderlines. Bateman and Fonagy (2004) call this central issue the “psychic equivalence.” Several EMDR specific procedures for differentiation have been proposed (Litt, 2007).

Working With Dissociative Parts of the Personality.

We generally find degrees of structural dissociation (van der Hart et al., 2006) even in clients with BPD with milder dissociative symptoms. Dissociative parts of the personality may be perceived and described by clients as “different aspects” or as “changing reactions.” Exploring the presence of dissociative parts of the personality through concrete representations (drawings, little figures, etc.) is useful for clinicians in developing and refining a deeper case formulation and for clients in developing capacities for reflective thinking and a metacognitive perspective (van der Hart, Groenendijk, Gonzalez, Mosquera, & Solomon, 2013, pp. 8–9). A shared understanding of these diverse aspects of the personality is essential to successful trauma reprocessing with EMDR (Gonzalez & Mosquera, 2012). In cases where structural dissociation is not prominent, it is not necessary to work with dissociative parts of the personality for a long time, but a specific exploration of these aspects in the preparation phase often helps to prevent or to resolve difficulties during Phases 3–7.

Pacing the Therapeutic Process.

When starting reprocessing, the decision-making process for target selection and sequencing may be influenced by many factors both in clinician and patient (Leeds & Mosquera, 2012). Some clinicians (under the influence of an early idealizing countertransference of rescuing or saving the patient) may tend to move too rapidly toward uncovering traumatic material without first understanding the client’s capacity to cope with day-to-day difficulties as well as the client’s challenges in confronting traumatic material. On the other hand, either the client or the therapist may defensively avoid or delay trauma reprocessing because of a phobia of affect or a phobia for traumatic contents (McCullough, 1997; van der Hart et al., 2006).

Determining (Testing) Readiness for Processing

Selecting Targets.

In working with clients with BPD, selecting targets may be challenging for various reasons. There may be many relevant targets with many adverse life experiences and many unique or recurring traumatic experiences (Leeds & Mosquera, 2012; D. Mosquera, 2012b). On the other hand, in complex trauma cases, amnesia or fragmented memories may interfere with identification of crucial targets in the past. When there are clearly identified memories, defense and avoidance mechanisms may not allow them to be addressed directly. Instead, more preparation, psychoeducation, and stabilization work may need to be done. Not infrequently, the defensive, phobic avoidance surrounding certain memories (van der Hart et al., 2013) need to be the initial targets for reprocessing until sufficient specific fears are resolved and sufficient affect tolerance is developed.

Determining Readiness.

In accordance with the phase-oriented, consensus model (Courtois et al., 2009; van der Hart et al., 1989), Hofmann (2010) proposed that clients with significantly unstable C-PSTD should generally meet the following four criteria for stability before proceeding to uncovering and reprocessing of core traumatic memories: good self-care in day-to-day functioning, containment and self-soothing resources, connection with body sensations, and capacity to speak about a traumatic memory without dysregulation. Hofmann proposed that significantly unstable clients with C-PTSD who do not meet these criteria be offered RDI (Korn & Leeds, 2002), Constant Installation of Present Orientation and Safety (CIPOS; Knipe, 2010d), and reprocessing on everyday life targets (current triggers) until they become more stable. Clinicians who consistently elect to wait for these four conditions before starting with EMDR trauma reprocessing may end up waiting for years or may never arrive at the “necessary stability” at all. This “conservative” way of using EMDR may unduly delay or prevent many clients with BPD from benefiting from the core of EMDR therapy (Gonzalez & Mosquera, 2012).

In some cases, where clients with BPD lack good self-care and good self-regulation skills, trauma reprocessing can turn out to be well-tolerated and effective. These clients may become better regulated after limited trauma reprocessing, whereas other “less intense” interventions, which defer or avoid trauma memory confrontation—such as RDI or DBT—may not work as well with them. In some cases, there are no other available resources for the individual or he or she is running out of options. When this is the case, identifying the adverse and traumatic life experiences clearly linked to the most high-risk behaviors and debilitating problems and reprocessing them early in the therapy can be the most stabilizing intervention. With some clients, “going slow” and following a prudent approach is best. With other cases, a more direct approach is needed. Information from “therapeutic tests” is necessary to design a comprehensive case formulation.

Because clients who meet criteria for BPD can be so diverse in their individual organization and responsiveness to our interventions, we need to propose each intervention as an experiment and to carefully consider their responses within and between sessions as essential information for clinical decision making. As we observe evidence of clients with BPD tolerating our interventions and becoming more stable, we transition toward reprocessing the most relevant and sometimes increasingly disturbing targets. Some proposals to structure targeting and reprocessing will be described in the following text.

Different Pathways in the Treatment Plan of BPD.

Clients with BPD present different specific situations that influence the pathway the therapeutic process will follow. With the progressive approach, we can start working from more tolerable tasks to more challenging tasks that make use of EMDR therapy with BLS. In general, when working with clients with BPD (apart from the dissociative subtype), five basic options for EMDR interventions may be considered from the more tolerable and accessible to the more difficult to deal with and access:

Client Characteristics That Guide Target Sequencing.

Specific client characteristics must be kept in mind to guide target sequencing and to organize a therapeutic plan. Here are some examples of the decision-making process:

Adaptations in the Assessment Phase.

Having selected a proposed target for reprocessing, it is important to remain alert to additional cautions during Phase 3. The work with selecting negative and positive cognitions sometimes needs simplification and help from the therapist. Although it is useful to know which negative cognition is most strongly related to the target, it is essential to prevent clients with BPD from getting completely lost in a growing cascade of negative self-beliefs. Clients with BPD usually have many strong negative self-beliefs. They often have difficulties when it comes to selecting just one as most strongly connected with a particular experience (Leeds & Mosquera, 2012; D. Mosquera, 2012b). To build their capacity for mentalization (Bateman & Fonagy, 2004), it is highly therapeutic for clients with BPD to recognize that their self-concept emerged from specific (external) experiences. So this standard aspect of Phase 3 is a highly relevant and potentially adaptive intervention that should be retained in the standard EMDR procedure. However, clients who tend to become overwhelmed with this step need more help from the therapist to avoid becoming overwhelmed or lost. For example, the therapist might say, “I know this is difficult and that many negative statements might be coming up for you now, but please try to think about the situation and pick the one statement that fits best. Take the time you need.” Or the therapist might say, “When you focus on that memory and the feelings that it brings up for you, are they more related to a sense of lack of control, a sense of immediate danger, or a sense of worthlessness?” At the same time, therapists need to be alert to avoid doing the work in this step for the client such as by initially offering a specific negative cognition. Psychoeducative information can be included, and reflective thinking should be stimulated.

Not infrequently with clients with BPD, identifying a positive cognition (PC) can be more challenging than identifying a negative one. Patients who lack early experiences of shared, interpersonal positive affect and recognition (Leeds, 2006) may lack the positive affect tolerance or the positive self-schemas to name even the simplest self-affirming self-statements. In some cases, specific work on positive affect tolerance can be helpful prior to proceeding with trauma reprocessing. In other cases, the PC initially proposed by the client may be an idealized and not realistic idea that should be modified with guidance from the therapist through a collaborative discussion with the patient. Simple examples include “It never happened,” “I can have everything under control,” or “I am invincible.” A more subtle example might be a client who offers “I am strong” as the PC when the negative cognition was “It is not safe for me to show my needs or ask for help.” Here, the idea of being “strong” is actually a defense against the vulnerability of asking for what one needs. In any case, an appropriate PC should be selected before proceeding to Phase 4 (desensitization), or the client would be exposed to a reprocessing that goes from negative to negative, without connecting at any point with positive memory networks. If a strong, specific PC is not possible (“I am a good person”), a bridging one can be chosen, such as “I can learn to accept myself as I am.”

Adaptations in the Desensitization Phase

Ending the Session.

The standard EMDR procedural steps and principles for reprocessing to individuals with PTSD without BPD or DESNOS are oriented toward striving for a completed session. However, when offering reprocessing to individuals with BPD, it is better to do a modest amount of good work and finish with an incomplete session than to push to try to complete reprocessing on a specific target (Leeds & Mosquera, 2012). Indeed, when working with clients with BPD, it is often prudent or necessary to bring sessions to a close when technically incomplete. When sessions are incomplete, therapists may consider a series of steps toward closure. These include inquiry into the client’s level of emotional and somatic activation; interventions for self-soothing, grounding, and presentification; session review with an emphasis on “mentalization”; brief installation of metacognitive statements reflecting any gains; and suggestions for homework or rehearsal of self-care.